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Unpasteurized Milk (UPM) Is Fresh and Has Not Undergone Heat Treatment (Pasteurization)

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Unpasteurized Milk (UPM) Is Fresh and Has Not Undergone Heat Treatment (Pasteurization) Nadine Ijaz MSc Copyright 2013 GRAND ROUNDS PRESENTATION BC Centre for Disease Control May 16, 2013 (Updated July 8, 2013) NOTE: In order to accommodate numerous requests for references, this presentation is now available as a .pdf file. The original Grand Rounds presentation has undergone minor modification to account for previous misinterpretation of a passage pertaining to risk characterization in J Food Prot 2012, 75(11):2036 Revised content (slides marked with *) will clarify the discussion of raw milk risk This clarification does not significantly affect the presenter’s conclusions To review evidence around health and safety claims for raw milk To deconstruct myths propagated on various sides of the debate To consider how evidence relates to current regulatory frameworks in Canada Not neutral: I advocate for regulatory reform Independent and unfunded research What is raw milk? Raw, or unpasteurized milk (UPM) is fresh and has not undergone heat treatment (pasteurization) Why pasteurization? intended to significantly reduce potential human pathogens in milk, as well as increase milk’s shelf life Raw milk prohibition: Canada’s federal Food and Drug Act (1990) explicitly prohibits UPM sales A bit unusual: Canada is the only G8 country to completely outlaw UPM sales ◦ Producers of raw milk regulated across European Union ◦ Laws vary across U.S. states (legal in majority of states) BC Milk Industry Act (1996): ◦ Federal sales ban extended to prohibit supply and distribution BC Public Health Act–Health Hazards Regulation (2011): ◦ Singles out UPM (and no other food) as a health hazard Similar effect: Ontario Health Protection & Promotion Act (1990) + Ontario Milk Act (1990) Raw milk consumption is legal: ◦ Producers may consume ◦ Legal to bring back $20 worth (daily) from U.S. From Health Canada: (Health Canada 2011) There are some Canadians who continue to prefer raw milk because of perceived health benefits. However, any possible benefits are outweighed by the serious risk of illness from drinking raw milk. From the BC Centre for Disease Control (BCCDC 2012): Raw milk is unsanitary and may contain feces, urine, and other environmental contaminants from the source animal and its environment. Heat treatment of milk (pasteurization) kills most bacteria in milk. Several studies and tests confirm that raw milk can contain a number of disease causing organisms. The “big four” include Listeria, Salmonella, E. coli O157:H7, and Campylobacter. Many of these organisms can cause severe illnesses that, in some cases, may have permanent effects. In severe cases, illness resulting from these four organisms can even cause death. People with compromised or undeveloped immune systems such as the elderly, people with certain chronic diseases, pregnant women, and young children are particularly vulnerable. Dairy farmers ◦ ~90% of Canadian dairy farmers consume milk raw (Young et al 2010) Small non-farming demographic ◦ 3% of U.S. population (US CDC 2007) ◦ Fewer in Canada? Difficult to access raw milk Raw milk consumers give importance to scientific (‘health benefits’, ‘safety’) as well as other criteria (Berg 2008) Taste (Headrick et al 1997, Hegarty et al 2002, Katafiasz & Bartlett 2012) Convenience and lower cost (amongst farmers) (Hegarty 2002, Jayarao 2006, Kaylegian et al 2008) Preference for ‘natural’, ‘local’, ‘traditional’ foods (Enticott 2003b, Hegarty 2002) Food sovereignty values (Berg 2008, Paxson 2008) Concerns with dominant industrial food production systems (Berg 2008, Enticott 2003a, Kaylegian et al 2008) Low confidence in dominant scientific and public health models (Berg 2008, Enticott 2003a, 2003b; Katafiasz & Bartlett 2012, Paxson 2008) SOURCES Above: Adams 2012 Right: Health Banquet 2013 What is a herdshare? ◦ Contract/c0-ownership model ◦ Shareholders pay herd maintenance fees to farmer/agister ◦ Members access milk from herd for personal use ◦ No direct milk sales involved Are herdshares legal? ◦ Explicitly legal in a number of U.S. states ◦ Before the courts in B.C. and Ontario Source: Google photos 2012 Source: Del Giudice 2011 Commercial raw milk from Herdshare farmers M. Schmidt California (Ontario) & A. Jongerden (BC) Myth #1: Raw milk is more digestible for people with lactose intolerance Myth #2: Enzymes and beneficial bacteria in raw milk make it more digestible for humans Myth #3: Raw milk is shown to prevent cancer, osteoporosis, arthritis, diabetes Myth #4: Raw milk is a high-risk food Myth #5: Raw milk has no unique health benefits Myth #6: Industrial milk processing is harmless to health No evidence to support raw milk being more digestible for persons with lactose intolerance ◦ No lactase (β-galactosidase) enzyme present in freshly drawn milk (Claeys et al 2013) ◦ Levels of lactase-producing lactobacilli in raw milk are much too low to achieve such an effect at refrigeration temperatures (Claeys et al 2013) ◦ Recent (unpublished) trial shows no connection (Vu et al 2010) Why do so many raw milk drinkers identifying as lactose-intolerant claim it’s easier to digest? (Beals 2008) ◦ People mistakenly diagnosed / self-identifying as lactose- intolerant (Paajanen et al 2007, Vu et al 2010) ◦ Other factors possibly making raw milk (seem) more digestible? Need more research; no substantial existing research Digestive enzymes in raw milk? ◦ No evidence that indigenous enzymes found in raw milk, or those produced by its bacteria, play a role in human digestion (USFDA 2011a, Claeys et al 2013) ◦ Biological effects of numerous milk enzymes currently unknown (Claeys et al 2013) Beneficial bacteria in raw milk? ◦ Possible effects of small quantities of indigenous ‘probiotic’ strains / commensal lactic acid bacteria in UPM (Claeys et al 2013) on human microbiome and health are largely unknown (von Mutius 2012) ◦ UPM’s commensal flora do appear to mitigate human pathogens found in raw milk (Claeys et al 2013) Numerous anecdotal claims Two recent evidence-based reviews, one of which is a meta-analysis, report: Cancer: no evidence for changes to onset or incidence (two studies) (MacDonald et al 2011) Diabetes: limited, controversial evidence (Claeys et al 2013) Arthritis & Osteoporosis: no current evidence (Claeys et al 2013) Consumption of nonpasteurized dairy products cannot be considered safe under any circumstances. ~(Langer et al 2011: 390) * Drinking raw (untreated) milk or eating raw milk products is “like playing Russian roulette with your health.” ~ (J. Sheehan, US FDA, in Bren 2004: 29) Source: Hallett 2013 Standard food safety measures: ◦ Risk per serving, risk per consumer ◦ Rate of morbidity, hospitalization (severity), mortality ◦ Differentials for immunologically susceptible groups Key considerations: ◦ Significance of risk (low, moderate, high) ◦ Possible mitigation strategies International food safety standards for microbial risk assessment have been established by the United Nations (Codex 1999) Canada is committed to science-based microbial risk assessment with respect to food safety (Health Canada 2007) ‘Gold standard’ method is to undertake ‘Quantitative Microbial Risk Assessment’ (QMRA) studies Farm-to-table mathematical models: incorporate dynamics of pathogen prevalence, dose-response, host factors, storage, etc. to establish: ◦ Risk per consumer or risk per serving ◦ Probability of morbidity, severe outcomes, mortality ◦ Risk by demographic and/or immunologic status Figures inform qualitative characterization: ◦ Low, moderate or high risk Escherichia coli 0157 and Campylobacter jejuni related to consumption of raw milk in a province in Northern Italy. J Food Prot. 75:2031-2038. (Giacometti et al 2012a) Quantitative risk assessment of listeriosis due to consumption of raw milk. J Food Prot. 74:1268-1281. (Latorre et al 2011) ◦ Methodology improved upon a previous 2003 U.S. government assessment (US FDA, FSIS et al 2003) Quantitative microbial risk assessment for S. aureus and Staphylococcus enterotoxin in raw milk. J Food Prot. 88:1219- 1221. (Heidinger et al 2009) As yet, no high-quality QMRAs for Salmonella spp. and raw milk ◦ Major methodological weaknesses in an older assessment for Salmonella dublin (Richwald 1988) Important to establish accuracy: ◦ Mathematical models don’t always represent reality (Jordan et al 2006) ◦ Possibility of flawed inputs How to confirm: ◦ Codex recommends corroborating QMRA figures with epidemiological foodborne outbreak data (Codex 1999) *Low risk QMRA calculation: 2011 QMRA risk per serving estimates (Latorre et al 2011) across all demographic groups (including perinatal and elderly) fall within range designated by US FDA as indicative of low risk (US FDA 2003) No confirmed illnesses over last 40 years: ◦ Despite L. monocytogenes prevalence rates in UPM being comparable to known causes of illness (Campylobacter, Salmonella, STEC) ◦ Claeys et al 2013: report but do not cite two ‘non-European’ cases which I have unsuccessfully tried to locate ◦ US FDA, FSIS et al 2003: cite two ‘European’ cases which, when checked do not bear out Listeria QMRA results (low risk) = reasonable ◦ Low significance attributed to high infectious dose + competitive exclusion from UPM commensal flora (claeys et al 2013) ◦ Contradicts ‘very high risk’ estimate in previous U.S. government QRA (US FDA, FSIS et al 2003) Notably lower risk than home-cooked chicken: Per-serving QMRA figures contrast with chicken QMRA risk estimates, suggesting significantly lower risk profile for raw milk Exposure type Risk per Location/Source
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